The end of pathology?

[Stairmaster]

Medicare restructured the way pathologists were compensated about 20 years ago and it has remained stable since (except for the fact that they have ratcheted down the amount of money per billing code to where it is now at 35% what is was in the 80s). The deal was that we would bill per container received. If one patient had 10 containers in one case, we could bill the appropriate code for each container (most commonly 88305). Well now medicare wants to change it so that starting next year we can only bill one (to at most two codes) per patient for any given day.

What this means is that if we could make $350 on those ten skin biopsies ($35 per container) for one case, now we will only make $35-$70 (one-two codes for the patient that day).

If this goes through, pathologists incomes are going to get slashed enormously (insurance companies will follow suit as they have done so for the last 20 years). This will be a huge blow to private practice and academic centers and anyone else who is compensated by medicare or insurance. I suppose Kaiser pathologists will be safe.

If those goes through, get out of path. This is way more of a threat to pathologists than even the path mills who are willing to split fees with big GI, Derm or uro groups to read their slides.

Please contact CAP and let them know this has to be their #1 focus.

Here is the memo that is www.cap.org.


College Develops Response to Units of Service Limitations
The College is reviewing closely and will comment on a Medicare contractor's proposal for units of service limits, called "medically unbelievable edits" by the Centers for Medicare and Medicaid Services (CMS), that appear to have been developed without regard to current coverage or policy guidelines.

Under the proposal, recently provided to the CAP and other specialty societies for review, local carriers would use the edits to test claims for a beneficiary on a given date of service against a limit for units of service. CMS has stated that the edits are intended to catch "typographical errors and unbelievable cases" submitted to Medicare for payment.

The edits, whose use will result in automatic denials of all claimed units in excess of the criteria units of service ceiling, are far-reaching: They affect the majority of pathology services and include CPT codes for all other specialties. Of particular concern to pathologists is the document's proposed limit of two units for CPT 88305 (Level IV—Surgical Pathology, Gross and Microscopic Exam) on claims for the same beneficiary on the same date of service for a given provider.

There is a 45-day comment period on the edits, with comments due by mid-January.

"We are actively reviewing the proposed edits to identify necessary modifications to the MUE list and are working now on a firm response," said Mark S. Synovec, MD, FCAP, Chair of the CAP Economic Affairs Committee. "We will develop clinical evidence of why these unit limitations are clearly inappropriate for pathology and pursue other measures, as appropriate, to fight this process, which appears to be seriously flawed."

Comments on the proposed MUE file could result in modifications or deletions. Use of the MUEs is proposed to start in July 2006.

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[yaah]

This is happening in every field of medicine, most likely, as well as in almost every profession in the world. The only surefire ways to make a lot of money are to be a professional athlete or a CEO. Everyone else gets their pay slashed.

I think it's irresponsible to say "get out of path" in response.

 

[Arsenic]

so whats going to happen, will you guys still be looking at 10 biopsies for a patient but only getting paid for 2? or will you just look at 2?

 

[Gut Shot]

Okay, then we'll just have to read 1-2 biopsies per patient per day until they're all done. That should make EVERYBODY happy.

Either that or strike! Strike!

 

[Stairmaster]

This is happening in every field of medicine, most likely, as well as in almost every profession in the world. The only surefire ways to make a lot of money are to be a professional athlete or a CEO. Everyone else gets their pay slashed.

I think it's irresponsible to say "get out of path" in response.

OK, maybe I should say "seriously consider getting out of path". Please provide evidence that lawyers, engineers, lab techs, teachers, real estate agents, even minimum wage workers have had their pay "slashed" over the last 20 years and are looking at a 66% cut in on year. Is the cost of buying a house being slashed? Is the cost of your kids medical school tuition being slashed? Are your med school loans being slashed? Believing that is being irresponsible or at least being in severe denial or severely delusional.

About 30 years ago, most pathologists received a cut of the hospitals clin lab income, and life was great. Many pathologists wouldn't even bill for surgical path or autopsies. They would just do it as a service to the hospital. Then medicare decided we need to bill like all physicians. The insurance companies followed suit. About 20 years ago they came up with a system and told us to bill per container based on the specimen's complexity. Your typical rectal polyp gets an 88305, a liver biopsy or lumpectomy gets a 88307. If the gastro biopsied the colon in 20 different places and puts them in 20 different specimen containers we bill medicare or the patient's insurace 20 different times.

20 years ago we were paid about $80 for an 88305. Over the next 20 years, medicare gradually cut our compensation for an 88305 (the professional fee for gross and diagnosis) to $30. This is the level it has been at for the last 4 years. We kept our salaries respectable by not hiring more people and signing out more cases ourselves. Also the number of biopsies went up over the last 20 years, so that helped too. However, it would be fair to say that most pathologists incomes ahve gone down 25-40% since the 80s.

Now the majority of pathologists (seasoned academics as well as private practice partners) earn 200-500K a year. A small percent might do better, and a small percent might do worse. Well, if this goes through we will be earning 66-166K a year.

If you have no hope of buying a nice house, a nice car, supporting a family and if you are fine with living in a 1br apartment, scraping by to pay off your med school debt, driving a late model car, not being able to pay your kid's college or med school tuition, then 100K a year must seem like a lot of money. Hell, it is twice what you earn now. If you love path to the point where you are willing to do it for free, then don't worry about this. If you are at the end of your career, then don't worry about it.

However, if you are in training and this goes through, you should consider soemthing else. GI, Cards, even OB or General Surgery, are all part of medicine, interesting, and for the benefit of society. Their pay won't be getting slashed 2/3 if this goes through. Radiologists, cardiologists and gastros are doing better than ever.

On the bright side, this legislation will drive out the anatomic path mill corporations, either that or they will have to find people that will do the job for 40K a year if they still want to earn their millions.

 

[Stairmaster]

so whats going to happen, will you guys still be looking at 10 biopsies for a patient but only getting paid for 2? or will you just look at 2?

We will look at all of them, but we will only be able to bill 1-2 codes per patient per day.

 

[Doctor B.]

Thankfully, that's why we have groups like the CAP. They can fight this sort of thing and hopefully keep it from going into effect.

I really don't think jumping ship to another specialty is a viable option for many of us. I'm nearly done with residency and would not relish starting over in a different field, especially if it involves direct patient care.

 

[Stairmaster]

Thankfully, that's why we have groups like the CAP. They can fight this sort of thing and hopefully keep it from going into effect.

I really don't think jumping ship to another specialty is a viable option for many of us. I'm nearly done with residency and would not relish starting over in a different field, especially if it involves direct patient care.

Yes, hopefully CAP will take care of this. This change in billing is meant to address other areas of medicine (a doc shouldn't be billing for 5 colonscopies in one day. that would be a clear error). However medicare tends to kill flies with sledge hammers. This would crush path, when the whole time we have been doing as we were told. I think CAP will get it worked out and get it ammended for us.

As far as switching, I understand, but in the long it would be worth it. And remember patients aren't nearly as nasty as surgeons.

 

[drPLUM]

Yes, hopefully CAP will take care of this. This change in billing is meant to address other areas of medicine (a doc shouldn't be billing for 5 colonscopies in one day. that would be a clear error). However medicare tends to kill flies with sledge hammers. This would crush path, when the whole time we have been doing as we were told. I think CAP will get it worked out and get it ammended for us.

As far as switching, I understand, but in the long it would be worth it. And remember patients aren't nearly as nasty as surgeons.

Just curious (and I am path applicant BTW).

If a GI doc does five colonoscopies in one day why shouldn't he bill for 5?
I don't know much about business/billing but this doesn't seem wrong to me.

 

[LADoc00]

Medicare restructured the way pathologists were compensated about 20 years ago and it has remained stable since (except for the fact that they have ratcheted down the amount of money per billing code to where it is now at 35% what is was in the 80s). The deal was that we would bill per container received. If one patient had 10 containers in one case, we could bill the appropriate code for each container (most commonly 88305). Well now medicare wants to change it so that starting next year we can only bill one (to at most two codes) per patient for any given day.

What this means is that if we could make $350 on those ten skin biopsies ($35 per container) for one case, now we will only make $35-$70 (one-two codes for the patient that day).

If this goes through, pathologists incomes are going to get slashed enormously (insurance companies will follow suit as they have done so for the last 20 years). This will be a huge blow to private practice and academic centers and anyone else who is compensated by medicare or insurance. I suppose Kaiser pathologists will be safe.

If those goes through, get out of path. This is way more of a threat to pathologists than even the path mills who are willing to split fees with big GI, Derm or uro groups to read their slides.

Please contact CAP and let them know this has to be their #1 focus.

Here is the memo that is www.cap.org.


College Develops Response to Units of Service Limitations
The College is reviewing closely and will comment on a Medicare contractor's proposal for units of service limits, called "medically unbelievable edits" by the Centers for Medicare and Medicaid Services (CMS), that appear to have been developed without regard to current coverage or policy guidelines.

Under the proposal, recently provided to the CAP and other specialty societies for review, local carriers would use the edits to test claims for a beneficiary on a given date of service against a limit for units of service. CMS has stated that the edits are intended to catch "typographical errors and unbelievable cases" submitted to Medicare for payment.

The edits, whose use will result in automatic denials of all claimed units in excess of the criteria units of service ceiling, are far-reaching: They affect the majority of pathology services and include CPT codes for all other specialties. Of particular concern to pathologists is the document's proposed limit of two units for CPT 88305 (Level IV—Surgical Pathology, Gross and Microscopic Exam) on claims for the same beneficiary on the same date of service for a given provider.

There is a 45-day comment period on the edits, with comments due by mid-January.

"We are actively reviewing the proposed edits to identify necessary modifications to the MUE list and are working now on a firm response," said Mark S. Synovec, MD, FCAP, Chair of the CAP Economic Affairs Committee. "We will develop clinical evidence of why these unit limitations are clearly inappropriate for pathology and pursue other measures, as appropriate, to fight this process, which appears to be seriously flawed."

Comments on the proposed MUE file could result in modifications or deletions. Use of the MUEs is proposed to start in July 2006.

I just heard this crap as well. We are seriously screwed if it goes through.

 

[LADoc00]

OK, maybe I should say "seriously consider getting out of path". Please provide evidence that lawyers, engineers, lab techs, teachers, real estate agents, even minimum wage workers have had their pay "slashed" over the last 20 years and are looking at a 66% cut in on year. Is the cost of buying a house being slashed? Is the cost of your kids medical school tuition being slashed? Are your med school loans being slashed? Believing that is being irresponsible or at least being in severe denial or severely delusional.

About 30 years ago, most pathologists received a cut of the hospitals clin lab income, and life was great. Many pathologists wouldn't even bill for surgical path or autopsies. They would just do it as a service to the hospital. Then medicare decided we need to bill like all physicians. The insurance companies followed suit. About 20 years ago they came up with a system and told us to bill per container based on the specimen's complexity. Your typical rectal polyp gets an 88305, a liver biopsy or lumpectomy gets a 88307. If the gastro biopsied the colon in 20 different places and puts them in 20 different specimen containers we bill medicare or the patient's insurace 20 different times.

20 years ago we were paid about $80 for an 88305. Over the next 20 years, medicare gradually cut our compensation for an 88305 (the professional fee for gross and diagnosis) to $30. This is the level it has been at for the last 4 years. We kept our salaries respectable by not hiring more people and signing out more cases ourselves. Also the number of biopsies went up over the last 20 years, so that helped too. However, it would be fair to say that most pathologists incomes ahve gone down 25-40% since the 80s.

Now the majority of pathologists (seasoned academics as well as private practice partners) earn 200-500K a year. A small percent might do better, and a small percent might do worse. Well, if this goes through we will be earning 66-166K a year.

If you have no hope of buying a nice house, a nice car, supporting a family and if you are fine with living in a 1br apartment, scraping by to pay off your med school debt, driving a late model car, not being able to pay your kid's college or med school tuition, then 100K a year must seem like a lot of money. Hell, it is twice what you earn now. If you love path to the point where you are willing to do it for free, then don't worry about this. If you are at the end of your career, then don't worry about it.

However, if you are in training and this goes through, you should consider soemthing else. GI, Cards, even OB or General Surgery, are all part of medicine, interesting, and for the benefit of society. Their pay won't be getting slashed 2/3 if this goes through. Radiologists, cardiologists and gastros are doing better than ever.

On the bright side, this legislation will drive out the anatomic path mill corporations, either that or they will have to find people that will do the job for 40K a year if they still want to earn their millions.

My new plan is to marry rich. Who is with me on that??

 

[Stairmaster]

Just curious (and I am path applicant BTW).

If a GI doc does five colonoscopies in one day why shouldn't he bill for 5?
I don't know much about business/billing but this doesn't seem wrong to me.

He can't bill 5 codes on the same patient the same day. He can bill 5 on 5 different patients.

In path we bill the same code on the same patient as we bill specimens and multiple specimens can be removed from the same patient on the same day. But this new proposal will screw us all, academics and private practice types both. Kaiser and county jobs will become the most desriable jobs.

This really isn't proposed to address pathologists directly. However, it is concerning that we were not specificly listed as not part of the proposal. This will seriously destroy our profession. It is one thing to take a 3% or 5% cut but taking a 60-70% cut is a huge F U.

If you are in medical school or early in residency, follow these events carefully.

 

[drPLUM]

This really isn't proposed to address pathologists directly. However, it is concerning that we were not specificly listed as not part of the proposal. This will seriously destroy our profession. It is one thing to take a 3% or 5% cut but taking a 60-70% cut is a huge F U.

What were other exceptions? Were we just not consideredin the first place or considered and included?

 

[LADoc00]

Just in my conversations so far today, if this were to take effect, it would be insane, like every private group would crump nationwide, there is NO way this could happen.

 

[Stairmaster]

What were other exceptions? Were we just not consideredin the first place or considered and included?

It is to be a uniform policy for all medicare claims (and like I said, private insurance mimics medicare policy).

Pathology specimens should have been listed as a specific exclusion.

It is scary that this was going to go through "under the radar". CAP has to make modifying this policy its number one priority.

After that they need to do away with large groups of urologists, gastros etc... from forcing pathologists to split the fee for the work. Fee splitting is highly unethical, but it goes on all the time. CAP needs to work with state medical boards to punish groups involved in that business. This is a big problem for outpatient radiology too. I know a neurosurgery group that sends their images out of state to a radiology group that will give them a kick back because the local in house radiology group wouldn't go for it.

 

[drPLUM]

So is the general opinion?

If this passes then it will in fact severely damage our profession, likely putting many out of work. But it will likely not pass, or at least not apply to pathologists if it does pass, because CAP is on top of it.

 

[Stairmaster]

So is the general opinion?

If this passes then it will in fact severely damage our profession, likely putting many out of work. But it will likely not pass, or at least not apply to pathologists if it does pass, because CAP is on top of it.

I don't think it will pass either, but if it did slip through...then they might as well just take us out to pasture and shoot us too.

One thing you learn in medicine is that greed rears its ugly head over and over. Take for instance fee splitting or the neurosurgeons trying milk an extra nickle out of radiology territory when they already make a great living as it is. In fact everyone who can is trying to get a piece of the radiology pie. It really makes for bad energy in the medical community. Fortunately no one wants to read their own path (except for the dermies), so we don't have to worry about that.

However, in this case we aren't being greedy we just don't want our incomes slashed over 2/3 in one year due to a rule change.

 

[PathOne]

True, the proposal is pretty radical... Already, you have paths looking at 200, 300 slides, where they'd previously look at 40-60. Still, this new idea makes very little sense. So, I'm to stand up in med mal court and say: "Yes, sir, I only looked at two slides, and I wasn't sure they were representative. But I could only bill for those two, and since I have overhead and a family to feed, I had to move on..."

Still, even if this new proposal gets kicked, I'm not that optimistic about future limitless upside income earnings potential in Path (or most other specialities for that matter, perhaps with the exception of Rads)...

 

[Cabbage Head]

True, the proposal is pretty radical... Already, you have paths looking at 200, 300 slides, where they'd previously look at 40-60. Still, this new idea makes very little sense. So, I'm to stand up in med mal court and say: "Yes, sir, I only looked at two slides, and I wasn't sure they were representative. But I could only bill for those two, and since I have overhead and a family to feed, I had to move on..."

Still, even if this new proposal gets kicked, I'm not that optimistic about future limitless upside income earnings potential in Path (or most other specialities for that matter, perhaps with the exception of Rads)...

I agree with you except for the "exception of Rads" part. If one thing in medicine has held true in the last 25 years, it's that everyone's turn to get a pay cut comes at some point. The only people who haven't really been affected are those who only work for cash money. True, radiology will always make someone money, but it might not be radiologists. I mean the hospital bills 5k for a spinal MRI, but how much of that goes to the radiologist? Or, look at CP...massive, automated chemistry outfits make a ton of money for whoever owns it, but it doesn't make money for the pathologist. Then again, radiology is a bit more involved than signing off on a chemistry protocol.

 

[Aubrey]

Still, even if this new proposal gets kicked, I'm not that optimistic about future limitless upside income earnings potential in Path (or most other specialities for that matter, perhaps with the exception of Rads)...

I don't think anything except for investment banking has limitless upside earning potential these days (certainly nothing in medicine). It seems inevitable that someone will eventually decide that there is a certain number of slides a pathologist will be able to interpret in a day, with similar justification to that which they used in the 80 hour resident work week decision. They may even consult some pathologists before they decide on a number. 🙄